Best Prostate Cancer Treatment Options If You Have BPH Symptoms?

I just finished Radiation treatment for prostate cancer with reason score 3+4. My symptoms of BPH slightly improved after treatment. Decision to go with radiotherapy rather surgery were the concerns of leaking and the long recovery.

@dbee First and foremost -- Always get a 2nd or 3rd opinion of your Biopsy results . I speak from experience . Also refer to Dr. Patrick Walsh's book " Guide to Surviving Prostate Cancer .
A true Gleason Score determines yoour treatment options . I am on Active Surveillance - 80cc prostate volume with BPH . I was initially on Flowmax for several years and have been on Dutasteride for 5 years to reduce the size of my prostate . Be aware that certain medications to treat BPH also lowers your PSA . For example if you are on Dutasteride like me for an extended period -- You have to double your LAB PSA . My Lab PSA is 8.4 my true PSA is therefore 16.8 .
This is critical when monitoring your PSA Velocity. . In your situation , even if you discover your Gleason Score is higher -- Research Monotherapy SBRT 5 Sessions ( 3 one week and 2 the next - alternate days ) . If you choose , you can have Rezum to address BPH and still have radiation .
Good luck -- Rember Don't panic and make a knee jerk , wrong treatment decision . Continue to educate yourself . And finally make a sound , educated decision .
In addition to TULSA PRO . NanoKnife is fast becoming a successful Focal Treatment worldwide , with the exception . The USA is slower .

I saw this thread bumped and thought I'd give an update. 2024 was a strange year. My second biopsy found no cancer and the second MRI found no change in the size of the existing cancer lesion that was found previously in the first MRI and biopsy. So how is that possible? Most likely the lesion is small enough that the sampling from the second biopsy just didn't happen to capture any cancer cells. Good news for sure. I was relieved and Mayo said I could go 3-5 years before another biopsy. Awesome. However...

My PSA number in Jan 2025 came in high at 7.6. I had a partial TURP surgery (the median lobe only) in the summer of 2024. That helped my BPH symptoms some, but since then I've still had some issues and started taking Tamsulosin again. So it's possible the higher PSA is from irritation due to BPH, or something else.

I meet with the local urologist next week. I assume they will recommend another MRI which I will do either at Mayo, or have Mayo read it if I have it done locally in my city. I'm still trying to figure out whether another BPH treatment will have to be done before undergoing radiation, if the next MRI and next biopsy show an evolution of the cancer to something that needs treatment. I've thoroughly researched the BPH treatments and am pretty sure I would do aquablation or HoLep if treatment is necessary before radiation for the cancer. Appreciate all the input.

@dbee I would highly recommend a 2nd or 3rd opinion of your 1st Biopsy Gleason Score ( Pathology Report ) John Hopkins comes to mind . They likely missed the target area on your 2nd Biopsy . Have you discussed Dutasteride with your Urologist to address your BPH problem
My 1st Biopsy was negative . My MRI PI-RADS Score was a " 5 " . In complete conflict with a negative biopsy . My 2nd Biopsy , supported by a 2nd & 3rd opinion of the results nailed down my gleason score -- Four Cores Gleason 3 + 3 = 6 , Two Cores Gleason 3 + 4 = 7

One approach you might consider depending upon whether or not you actually have a cancerous lesion is focal therapy via TULSA-PRO procedure. I had this procedure done at Mayo Rochester in October, 2024. I had one cancerous lesion Gleason 3+4=7 and a 100cc prostate due to BPH. In this one procedure my doctor ablated the lesion and ablated 60% of my otherwise healthy prostate tissue. I'm approximately 4 months out from that procedure. He said once I heal I'll be peeing like a race horse..........and I am. So hopefully I've effectively killed two birds with one stone. I have my first MRI at Mayo in early April and my next PSA test. My 3 month PSA test my PSA dropping from 12.8 to 1.3. Since I still have a 40cc functioning prostate I would expect a PSA value. A value of 1.3 so far is well within the normal range. So far, so good.

This is a really interesting thought. I had originally ruled out the TULSA-PRO procedure. I had read somewhere that it is very difficult for the surgeon to ensure they get all of the cancer cells, plus the uncertainty of cancer cells growing elsewhere in the prostate. The re-occurance rates with TULSA I thought were significantly higher. Did you talk with your doctor about what treatment to pursue in the event of re-occurance? Overall, I like this idea if the re-occurance rates aren't too much worse than radiation or prostatectomy.

I'll give you my working assumptions.......I don't know if I'm right or wrong in this regard. I tried my best to gather good information in advance of making my decision. I would preface all of what I'm about to say with.......do your absolute best to have whatever procedure you have done, to have it performed at a center of excellence by as highly experienced a person you can have do it. I learned prostate cancer is multi-focal. So it can come back in another area of the prostate or the body for that matter if the entire prostate is treated (as with radiation or radical prostatectomy). What I found was the percentages (roughly 15-20%) of recurrence are about all the same no matter the procedure. I heard a lecture by Dr. Klotz who helped invent and promote TULSA-PRO where he said his experience was 85% of patients were still cancer free 5 years after the procedure. So my thinking was.........there can be a lot of advances in treating this disease over the next 5 years. If the cancer should come back inside the prostate which is my understanding of where it usually comes back for this treatment modality, it can be treated again with TULSA-PRO, or all forms of radiation are still available. I've lost nothing in terms of future options for treatment. That's my understanding. I have a 6 month in person appointment at Mayo in April. At that time when I meet with the doctor who performed my procedure, I may ask again the question............what if it comes back? The up and down side of this procedure is that for the next 2 or so years I'll be closely watched by Mayo (PSA test, MRI's, maybe biopsy if something shows up). I believe this is standard care for this procedure at all centers of excellence. So if the cancer returns, it will be caught very early on. And early treatment leads to better outcomes. That all said...............mentally I am not allowing this cancer to come back in my body. If others who read this see it differently, I'd appreciate the benefit of your learnings.

I also did Tulsa in July last year at Mayo Rochester. I did a lot of research and what sold me on Tulsa was the low risk of side effects, non surgical procedure, and all other options are still on the table if cancer returns. Also there was a study that came out about that time showing focal therapies were just as effective at 30 months as other options. I just had my 6 month MRI and no sign of cancer. My PSA is down from 8.6 to .96. My PSA was 2 fifteen years ago. My radiologist at Mayo has done over 3000 Ablations on cancers (not all prostate) and told me the Tulsa Pro system gives him a level of precision he does not have for most of the cancers he treats. I agree with pdcar that there will likely continue to be huge treatment improvements in the next 5 years and we have bought some time with no impact on quality of life.

I receive my care at Mayo Rochester. Who did you use for your Tulsa procedure?

Dr. David Woodrum.